Games with the AO rating are considered by the board to be suitable for players age 18 and over; AO-rated games can contain higher levels of violent, profane, sexual, or pornographic content than the next-lowest rating on the scale, Mature (M), which is generally considered suitable for players 17 and over, can accommodate. AO is the highest and most restrictive of the ESRB's content ratings, and dramatically impacts the commercial availability of games which carry it; all three major video game console manufacturers (Nintendo, Microsoft, and Sony Interactive Entertainment) refuse to allow AO-rated games to be published for their platforms, most retailers refuse to stock AO-rated games, and the popular video game live streaming service Twitch explicitly bans all games carrying the rating.[5] Due to these self-imposed restrictions on the marketing and distribution of games with the rating, the AO rating has been described as a "kiss of death" by critics.[6][7][8]

Relatively few games carry the AO-rating; the majority of AO-rated games are adult video games which received the rating for containing sexual and/or pornographic content, but the ESRB has also issued the rating for games containing extreme violence.[6] The fighting gameThrill Kill (1998) was given an AO rating for its violent content; its release was cancelled after the acquisition of its publisher, Virgin Interactive, by Electronic Arts, as they objected to the game's content. Rockstar Games' Manhunt 2 (2007) was the second game given an AO rating for extremely violent content, but was re-edited to meet the M rating so it could be released on consoles (an uncut, AO-rated version for Windows was released in 2009).[9]Hatred (2015), a game centering on a character indiscriminately murdering everyone he encounters, was the third game to receive the rating solely for violence.

Fellow Rockstar game Grand Theft Auto: San Andreas (2004) was temporarily re-rated to AO from M in response to the release of a mod known as "Hot Coffee", which allowed players to access a sexually-explicit minigame that was removed in development, but still present within the game's code in an incomplete state. The M rating was reinstated after Rockstar released patches and revisions of the game which excluded the content entirely.[10][11][12][13][14][15]

Unlike other self-rated games by MangaGamer, this game was sent to the ESRB at the request from the Japanese developer in order to get a green-lit for the hardcopy release in the United States.[30] The game was already self-rated 18+ for the digital release.

In North America, an M-rated edit of Fahrenheit was originally released under the title Indigo Prophecy; Quantic Dream CEO Guillaume de Fondaumière remarked that many players imported the uncut European release instead. A remastered version of the uncut game, released in 2016, was given a Mature rating.[32][33]

Originally rated M, San Andreas was temporarily re-rated AO following the discovery of an incomplete "Hot Coffee" minigame that could be enabled with a mod or cheating device, which featured characters engaging in sexual intercourse. Its rating was changed back to M after Rockstar patched the game to remove the offending content entirely.[10][35]

Manhunt 2 was originally given an AO rating, but was edited by Rockstar to meet the M rating so it could be released on consoles.[47] In 2009, an uncut version was released for PC.[46] Both cuts were also refused classification in the United Kingdom, but Rockstar successfully appealed for an "18" rating on the M-rated edit.[14][47][48]